Tuesday, May 24, 2016

In 1840, Hope came up with the term myiasis to distinguish the human disease caused by dipterous larvae. However, German entomologist Fritz Konrad Ernst Zumpt (1908-1985) is perhaps the name most closely associated with discovery of myiasis (for better or worse). Zumpt worked primarily in Africa and published several articles and a book on myiasis, called “Myiasis in man and animals in the Old World” in 1965. Of course, as many different kinds of flies are associated with myiasis, discovery of these many species were by various other etymologists (and unfortunate myiasis victims!).

Maggots have been used in medicine since before Zumpt’s time. While maggots may have been used in medicine by Mayan Indians and aboriginal tribes of Australia, the first documented uses of maggots were in Napoleon’s armies where surgeons noticed wounded soldiers with blowfly infestations survived better than those without. In 1829, Napoleon’s surgeon general, Baron Dominique Larrey, described observations that some flies destroyed dead tissue and aided wound healing.

American Civil War Army surgeons deliberately used blowfly maggots, placing the maggots into wounds to aid healing. The maggots would clean away decayed tissue and may also have aided in reducing the bacterial activity and incidence of secondary infection.

Continuing in this theme, blowfly maggots were commonly used in World War I to debride deep wounds. This use of blowfly maggots was subsequently continued in civilian practice. Since 1929, flies have also been used to treat chronic osteomyelitis (notably, it was Dr. William S. Baer who first did so. He had been in WWI and saw a patient therapy with maggots quite by accident- when a soldier left on the field returned much less ill than one would have expected given his injury. Once his clothes were removed, Dr. Baer saw that “thousands and thousands of maggots filled the entire wounded area.” Recent evidence points to Procteus mirabilis (which can be found in maggot salivary glands) may produce substances that kill pathogenic bacteria and promote wound healing.

Only a small number of flies that cause human myiasis are used in medicine. Good medicinal maggot candidates do not consume normal human tissue. Weil et al reported that that larvae of L. sericata starved on clean granulation tissue and suggested that they were, therefore, ideally suited for maggot therapy. Lucilia sericata is the most commonly used species in maggot therapy- this is rather ironic, given Sherman reported Lucilia as the species most highly associated with non-therapeutic wound myiasis in hospitalized patients! It is also a bane to the sheep raising populace, as it affects sheep strongly.

Maggot therapy is used most often with very serious infections, including temporal temporal mastoiditis and perineal gangrene (traditional surgical and antibiotic treatments have been ineffective). Rather than being used as a last resort, maggots are used as “an adjunct to modern medicine.” They are also used with diabetic patients, in treating foot wounds (a complication that sometimes occurs with diabetes).

An itemized list believed to be from former first lady Mary Todd Lincoln's funeral has resurfaced after two of the oldest funeral homes in Springfield merged.

The list shows her 1882 funeral cost almost $280, with expenses ranging from $225 for a casket to $1.50 for crepe and ribbon, the Springfield State Journal-Register reported.

A horse-drawn hearse with four attendants? Fifteen bucks.

The list was included in stacks of fragile ledgers acquired by Butler Funeral Homes of Springfield after last year's buyout of Boardman-Smith Funeral Home.

Butler Funeral Homes is creating a "Lincoln Room" where the Mary Lincoln Todd ledger entry will be displayed with other documents tied to Springfield's funeral history. Among the other items are a pair of funeral biers thought to have ties to the Lincoln family, but they haven't been verified.

Butler Funeral Homes President Chris Butler said employees of Boardman-Smith, which was founded in 1848, had taken care to store and label dozens of expense ledgers dating to the mid-1800s.

Butler said Boardman-Smith's connection to the Lincoln family is one of the attractions that prompted his company to go through with the merger but not the only one. The everday lives of ordinary town residents from another time were also full of fascinating tidbits he and his company want to share the spotlight with Lincoln.

"I'd love to know their stories," Butler told the State Journal-Register. "That family lost all of those children, or 'wow,' it's the 1800s and this person lived to be in their 90s."

Plans are to complete the Lincoln Room this summer, according to Butler.

Butler Funeral Homes President Chris Butler
Butler Funeral Homes President Chris Butler looks through ledgers kept by the Boardman-Smith Funeral Home in Springfield. Boardman-Smith, which was founded in 1848 and acquired by Butler last year, handled the funeral arrangements for Mary Todd Lincoln. (Rich Saal / The State Journal-Register)
At one time, Boardman-Smith was marketed as "The Lincoln Funeral Home" and was called upon to assist with the transfer and preparation of President Abraham Lincoln's body after his assassination in April 1865, according to company history.

Historians say Mary Todd Lincoln welcomed her own death in many ways after the death of her three sons and her husband. She outlined specific instructions for a funeral that was still eight years away in a letter to her son, Robert, which is among the collections at the Abraham Lincoln Presidential Library and Museum in Springfield.

She died in July 1882 at age 63 at her sister's home in Springfield.

While hardly grabbing the headlines of Abraham Lincoln's funeral after his very public murder in 1865, the death of Mary Todd at age 63 in 1882 was still a big event.

"The citizens of Springfield, the home and resting place of Abraham Lincoln, whose name has become canonized in the hearts of liberty lovers all over the world, and who will be gratefully remembered as long as free government continues to be appreciated by mankind," The Illinois State Journal reported, “have learned with profound sorrow of the death of Mary Todd Lincoln, his relief, and mother of his only surviving son."

The resurfaced documents will add much-needed texture to the lives of Lincoln's family, especially in the years after his assassination.

"It's important for us to remember these were living, breathing people," said Samuel Wheeler, research historian at the Abraham Lincoln Presidential Library and Museum. "Documents such as these help bring them to life."

Image: An itemized list of expenses believed to be from the 1882 funeral of Mary Todd Lincoln in Springfield. The list was in stacks of fragile ledgers acquired by Butler Funeral Homes through the company's buyout last year of Boardman-Smith Funeral Home. Butler is creating a "Lincoln Room" where the ledger will be displayed with other documents tied to Springfield history. (Rich Saal / The State Journal-Register)

Abstract
During the natural history movement of the 18th and early 19th centuries, Charleston as a center was rivaled in the United States only by Philadelphia, New York, and Boston. Prominent physician-naturalists included Alexander Garden (for whom the gardenia is named), John Edwards Holbrook (“father of American herpetology”), and Francis Peyre Porcher (whose Resources of Southern Fields and Forests helped Confederates compensate for drug shortages). The Charleston physician-naturalists belonged to an “aristocracy of talent” as distinguished from the “aristocracy of wealth” of lowcountry planters, who probably did more than any other group to perpetuate slavery and propel the South toward a disastrous civil war. None of the physician-naturalists actively opposed slavery or secession, a reminder that we are all prisoners of the prevailing paradigms and prejudices of our times.

INTRODUCTION
The South Carolina lowcountry elicits mixed emotions. Its beauty and diversity of flora and fauna bring out the joyous naturalist in a person, yet such sights as abandoned rice fields, tabby ruins of plantations and chapels-of-ease, and Civil War cemeteries remind us of a way of life based on African slavery. During the natural history movement (the descriptive study of the three major kingdoms—animal, vegetable, and mineral—during the 18th and early 19th centuries), Charleston as a center for naturalists, especially physician-naturalists, was rivaled in the United States only by Philadelphia, New York, and Boston. How did these men respond to slavery, that singularly defining fact of American history?

My text comes from a remark made sometime around 1830 at a dinner party: “Whatever parties may exist in a country, and under whatever names they may go, there are always two aristocracies—the aristocracy of wealth and the aristocracy of talent.” Turning to his guest, the speaker added: “You belong to one and I to the other”. The speaker was young Tom Heyward, scion of a rice-planting family. The South Carolina lowcountry planters, an argument goes, did more than any other group to perpetuate African slavery, defy the federal government and its constitution, propel the nation toward civil war, and establish a mindset that reverberates today in our hyperpolarized national psyche. The listener was a young lawyer named James Louis Petigru, who went on to such distinction that by the eve of the Civil War he is said to have been the only Unionist in South Carolina who could walk down the streets of Charleston or the aisle of St Michael's Church and gain a respectful nod from everyone he passed. To Petigru is attributed the famous mot that “South Carolina is too small to be a republic, and too large to be an insane asylum.”

The physician-naturalists constituted an aristocracy of talent. A few, to be sure, became planters and slaveholders, but most earned their livings practicing medicine. Their lives and achievements have been previously summarized, but, to my knowledge, no attempt has been made to situate all of them within their eras' general histories. This meeting's setting in downtown Charleston, the scheduling of this paper late in a program sated with basic and clinical science, and last evening's address on the bombardment of Fort Sumter by Professor James Rembert suggested it might be more useful to underscore the contexts of their times that to dwell at length on their specific contributions to natural history, which at this late hour might fly by like so much scenery. Let us then consider some of the more prominent Charleston physician-naturalists in four contexts: the colonial and revolutionary periods, during which the die was cast for a later reckoning on the slavery question; flush times between 1783 and 1830, when diversity of opinion on slavery was still tolerated; stormy years between 1830 and 1860, during which southern attitudes hardened; and the Civil War, which destroyed the aristocracy of wealth and effectively closed an era of physician-naturalists in South Carolina.

COLONIAL AND REVOLUTIONARY PERIODS: DR ALEXANDER GARDEN
Colonial Americans bent on studying medicine typically went to Edinburgh. Native Scots trained in Edinburgh often went elsewhere to practice, as the supply of doctors in Scotland exceeded the demand. The late Dr Joseph Waring determined that 17 of 28 doctors who practiced in Charleston between 1725 and 1780 were either born in Scotland, trained in Scotland, or, and more typically, both. During the colonial and revolutionary periods, the leading South Carolina naturalist by far was Dr Alexander Garden (1730−1791), a Scot who came here in 1752 seeking a milder climate for his lung condition, probably tuberculosis. He began practice in what is now Beaufort County but due to illness went north for a few years. There he met other naturalists and learned the Linnaean method of classification. Returning to South Carolina, Garden practiced with Dr John Lining, another Scottish immigrant remembered as a pioneering American meteorologist. Garden applied Linnaean taxonomy to the flora and fauna of South Carolina. He submitted botanical specimens to the British naturalist John Ellis, who read Garden's papers to the Royal Society and made Garden known to the great Swedish physician-naturalist Carl Linnaeus. The latter showed appreciation by naming the Cape jasmine the “Gardenia” and encouraged Garden to send animal specimens. Linnaeus eventually credited Garden for describing three new genera of plants, two new genera of fish, and 60 new species of serpents, insects, and fish. Garden's specimens were so well-prepared that many remain on display in London museums. His observations and experiments on electric eels drew the attention of London's John Hunter and others, contributing to a chain of events leading to the idea that human nerves and muscles might operate on electric impulses.

Garden's productivity as a naturalist becomes all the more remarkable when one considers his poor health, his probable attacks of malaria, the Carolina heat, and a practice that grew busier after Lining died in 1760. He was driven in part by a desire for recognition by European scientists. He held little hope for recognition by fellow colonists, telling Ellis that South Carolina was “a horrid country, where there is not a living soul who knows the least iota of Natural History”. Garden took a dim view of the lowcountry planters, writing that they were “absolutely above every occupation but eating, drinking, lolling, smoking, and sleeping, which five modes of action constitute the essence of their life and existence” (whether he left out sex inadvertently is unknown).

Also driving Garden like most naturalists was the desire to know God by studying His handiwork (natural theology; the “argument from design” for the existence of God). Thus, in 1763, Garden wrote Linnaeus of “the mental pleasure and rational employment, which I have had in examining, determining, contemplating, and admiring this wonderful part of the works and manifestations of the wisdom and power of the Great Author of Nature,” which was “so full and replete with innumerable marks of Divine” that Garden planned to devote full-time to it “as soon as my business of the practice of medicine will permit me”. Linnaean taxonomy was predicated partly on the idea that God had formed each creature independently; therefore, each species reflected a divinely created “original mold.” How Garden reconciled his pursuit of the divine with the harsh reality of slavery is unknown, but he made scathing observations on the slave trade.

More than 200,000 Africans were brought to South Carolina between the late 17th century and 1808, when the slave trade was officially abolished. Charleston's first English-speaking settlers came from the West Indies in 1670 as experienced colonists well-aware of the profitability of cash crops using slavery. The brutality of slavery in the hot and humid Carolina lowcountry prompted the Stono Rebellion of 1739, which resulted in the deaths of approximately 45 whites and an equal number of blacks. Whites' attitudes hardened but the slave trade resumed after brief suspension. Garden was among the doctors who examined newly arrived slaves quarantined on Sullivan's island, which became the Ellis Island for at least 40% (some estimates run as high as 60%) of today's African Americans.

Garden described the horrors to the British botanist Stephen Hales: “There are few Ships that come here from Africa but have had many of their Cargoes thrown overboard; some one-fourth, some one-third, some lose half; and I have seen that some that have lost two-thirds of their Slaves. I have often gone to visit those Vessels on their first arrival. .. but I have never yet been on-board one, that did not smell most offensive and noisome; what for Filth, putrid Air, putrid Dysenteries (which is their common Disorder), it is a wonder any escape with Life”. Nevertheless, Garden as a man of his times did not forswear slavery. Reputedly the colony's wealthiest doctor by the eve of the revolution, he bought a plantation only to have his enjoyment of a slaveholding planter's lifestyle cut short by the Revolution.

South Carolina was the wealthiest of the 13 colonies. If you belong to the privileged class, should you bet on the Continentals or the Crown? This question became urgent after Charleston fell to the British in early 1780, leaving Lord Cornwallis in charge. Garden tried to stay neutral. However, his signature on a memorial congratulating Cornwallis on his route of the Continentals at Camden (August 1780) proved his undoing.

South Carolinians taught the British a lesson (and a lesson apparently forgotten by US leaders beginning around 1960) that a well-equipped, well-fed, well-dressed occupying force from across an ocean may lose to insurgents who know the terrain, blend in with the population, use hit-and-run tactics, and are not answerable to public opinion in a faraway land. Francis Marion (“the Swamp Fox”), Thomas Sumter (“the Gamecock”), and other partisan leaders with their ragtag troops disrupted British supply lines between Charleston and the “backcountry.” Marion and his colleagues effectively wrote a manual on asymmetric warfare that is still studied. Backcountry farmers, many of them Scots-Irish with no particular fondness for the British, became enraged by occasional atrocities such as Banastre Tarleton's massacre at the Waxhaws (May 1780). They teamed with Continental regulars to win decisive battles at Kings Mountain (October 1780) and Cowpens (January 1781) and drive Cornwallis up through the Carolinas and then to Yorktown, where the British were trapped between George Washington's army and the French fleet. After the war, Garden became one of 13 doctors banished in 1783 as “obnoxious persons” for supporting the British cause. He returned to Great Britain, became vice-president of the Royal Society, and died there in 1791.

FLUSH TIMES (1783 TO 1830): MEDICAL EDUCATION AND BOTANY
The fate of America, it is suggested, may have been sealed during the Constitutional Convention of 1787 when a Charleston lawyer-politician named John Rutledge invited Roger Sherman of Connecticut to dinner. Rutledge chaired a committee that wrote much of the final version of the Constitution. Only 3 of the 13 states—the two Carolinas and Georgia—had a vested interest in perpetuating slavery indefinitely. Most southerners like most of the Founding Fathers tolerated slavery but predicted its eventual decline. Rutledge, perhaps through a lie, persuaded Sherman to vote with South Carolina on the slavery issue in exchange for which South Carolina would support Connecticut's desire to invest in western land through the Ohio Company (that is, to establish the Western Reserve). The slave trade was thus extended until January 1, 1808. Pierce Butler, another South Carolina delegate to the Constitutional Convention and one of the South's largest slaveholders, inserted a clause mandating return of fugitive slaves. Butler also promoted a compromise that allowed states to count three-fifths of the slave population for the purposes of Congressional apportionment. This gave the slave states disproportionate power in the new Congress, the first iteration of a “solid South” in American politics.

The half century that followed the Revolution brought flush times for lowcountry planters. They lost the British bounty for indigo (a plant from which blue dye was produced) but discovered the profitability of “Carolina gold” rice. Rice plantations lined stretches of rivers where fresh water rises and falls with the tides. The rice fields were alternately flooded and drained by harnessing tides with dikes, floodgates, and trenches—elaborate systems requiring large numbers of slaves to be cost-effective. By the 1820s, the population of Georgetown County, north of Charleston, was more than 90 percent black. The widow of a Georgetown rice planter wrote her son at West Point: “Rice [that is, the price of rice] fell badly, and that depresses the spirits of the Majority of the People here, whose chief object is to make Rice to buy Negroes and Buy Negroes to make Rice”. Malaria and other diseases rendered the rice plantations extremely insalubrious. The seasonality of malaria prompted one of the strangest migration patterns in the history of agriculture: the planters and their families absented their country homes during the growing and harvest seasons, taking extended summer vacations including the European Grand Tour. The lowcountry planters came to view slavery as a permanent necessity for their way of life.

Rice was, of course, not the only source of South Carolina's wealth. In 1793, Eli Whitney of Massachusetts, fresh out of Yale College, invented the cotton gin. Backcountry Carolinians turned forests into cotton fields. It is said with only slight hyperbole that one could have walked from Charleston to Walhalla (in the western corner of the state) without stepping out of a cotton field except to cross the occasional creek or river. Southern planters perceived two threats to their power in Congress: rapid population growth in the northern states and the possibility that western territories would become states that outlawed slavery. Tensions were appeased but not resolved by the Missouri Compromise of 1820, which banned slavery in the former Louisiana Territory north of the 36° 30' parallel (but allowed slavery south of it) except within the boundaries of the proposed state of Missouri.

Emblematic of South Carolina's prosperity during the early decades of the 19th century was the opening of the Medical College of South Carolina in Charleston, which at its creation in 1824 was the first such school in the Deep South. All but one of the seven charter faculty members had been graduates of the University of Pennsylvania, which had replaced Edinburgh as the destination of choice for American medical students. The exception was Stephen Elliott (1771−1830), whose honorary medical degree was conferred by the new school. Three of the seven charter faculty members were naturalists: Elliott, John Edwards Holbrook (1794−1871), and Edmund Ravenel (1797−1870).

During the early 19th century, many educated Americans took up botany. A South Carolina example was Joel Roberts Poinsett (1779–1851), who used the small fortune inherited from his father, Dr Elisha Poinsett of Charleston, to pursue a diplomatic career. In 1825 Joel Poinsett became America's first minister (ambassador) to Mexico, from which he brought back a flowering plant known there la flor de Nochebuena and to us as the poinsettia. Among the South Carolinian physicians who studied botany during this period, the most prominent were Elliott and John Lewis Edward Whitridge Shecut (1770−1836). Shecut's application of Linnaean taxonomy resulted in The Flora Carolinaensis, or a Historical, Medical, and Economical Display of the Vegetable Kingdom according to the Linnaean or Sexual System of Botany (1806). Shecut also experimented with electricity to treat various conditions, especially withered or paralyzed limbs, and wrote two novels. Elliott published between 1816 and 1834 a Sketch of the Botany of South Carolina and Georgia, a classic of American botany. Plants bearing his name include the shrub Elliotia.

Shecut and Elliott left little evidence of their views on slavery, which, however, changed after the slave trade ended in 1808. Slaves were treated better because they could no longer be replenished from Africa (or at least not legally). They no longer slept on bare ground. Many were taught Christianity. Many kept their own vegetable patches and some kept livestock. Some sold goods at markets such as the one directly across Meeting Street from where we now assemble. Charleston and other cities became home to an increasing number of free blacks, one of whom—a man known to history as Denmark Vesey—supposedly led an insurrection in Charleston in 1822. Although slavery became in some respects a kinder and gentler institution, white southerners' attitudes toward their “peculiar institution” and toward the federal government inexorably hardened.

STORMY YEARS (1830 to 1860): NATURALISTS AND THE THEORY OF POLYGENESIS
The naturalist movement in the United States peaked between 1830 and 1840; the years between 1830 and 1860 constituted a golden age for naturalists in South Carolina (7). Three physicians—Edmund Ravenel, Lewis Reeve Gibbes (1810−1894), and John Edwards Holbrook (1794−1871)—deserve mention, as does a Lutheran minister, the Reverend John Bachman (1790−1874). Their times were characterized politically by the doctrine of states' rights and by the “positive good” theory of slavery, ideas that led southerners down the primrose path toward secession and civil war.

The first flash point in South Carolina's journey toward secession was the Nullification Crisis, a reaction to the federal Tariffs of 1828 and 1832. South Carolinians considered these tariffs oppressive, designed as they were to protect northern manufacturing to the detriment of southern agriculture. In 1832 the state legislature passed an Ordinance of Nullification declaring federal tariffs null and void within the state borders. President Andrew Jackson sent naval forces to Charleston, warned South Carolinians not to commit treason, and supported a bill in Congress giving him power to enforce tariffs. A compromise ensued and South Carolina repealed the ordinance. However, an irreparable rift developed between President Andrew Jackson and his vice-president, South Carolina's John C. Calhoun. Calhoun, as a recent commentator puts it, “made it impossible to be both antislavery and reasonable”.

Calhoun popularized two theories later used to justify secession and civil war: the “theory of the concurrent majority” and the “positive good” theory of slavery. In his Disquisition on Government Calhoun railed against “the tyranny of the majority” and implied the rights of states to nullify acts of Congress. The positive good theory of slavery, first articulated by Thomas Dew of Virginia, held that blacks were incapable of self-government and benefitted from slavery. It was during the gathering firestorm fueled by Calhoun's theories that physician-naturalists Ravenel, Gibbes, and Holbrook contributed to their era's scientific thought.

Edmund Ravenel, who served as dean of the Medical College in Charleston from 1829 until 1834 when his health began to fail, spent summers on Sullivan's Island where he practiced medicine and collected seashells. Between 1827 and 1829 he befriended a soldier stationed at Fort Moultrie who had enlisted as “Edgar A. Perry” but whose real name was Edgar Allan Poe. In Poe's short story “The Gold Bug” the protagonist William Legrand, modeled in part after Ravenel, finds a bivalve mollusk on the beach at Sullivan's Island before being bitten by the scarab-like “gold bug.” In 1834 Ravenel published a catalogue of his collection, the first of its kind in the United States and containing more than 3500 shells. His collection is still intact in the Charleston Museum and some consider him the “father of American conchology.” Ravenel published on other scientific topics including geology, and in 1853 was a founding member of the Elliott Society of Natural History in Charleston. Lewis Reeve Gibbes was perhaps the most versatile of the Charleston physician-naturalists although, to be sure, he never practiced medicine after receiving his degree, electing instead to teach mathematics. In 1835, he published a “Catalogue of the Phaenogamous Plants of Columbia, S.C. and its Vicinity,” describing some 900 species.

The most eminent Charleston physician-naturalist of this period was John Edwards Holbrook, the first professor of anatomy at the Medical College of South Carolina. Holbrook is considered the “father of American herpetology” on the basis of his five-volume North American Herpetology; or a Description of the Reptiles Inhabiting the United States, begun in the 1820s and ultimately completed in 1842. He personally collected reptiles in every state from Maine to Georgia and named 29 new species. He then turned to fish. In 1847, and again in 1848, 1855, and 1860, he published treatises on the fish of South Carolina and neighboring states. Holbrook developed a vast network of naturalists including physicians to collect specimens—an early model of collaborative research. He insisted that his illustrations be drawn from life, which explains in part their high quality. A self-effacing man, Holbrook never made much money practicing or teaching medicine and spent much of what he earned on his collecting trips and book publishing. However, his devoted wife came from a wealthy slaveholding family and supported his scientific endeavors.

Edmund Ravenel, Lewis Gibbes, and John Holbrook belonged to a circle of naturalists led by the Reverend John Bachman. Born in Rhinebeck, New York, on the Hudson River, Bachman, similar to Garden before him, came to South Carolina seeking a better climate for tuberculosis. He served as minister of St John's Lutheran Church in Charleston from 1815 until his death in 1874. He is remembered eponymously for Bachman's sparrow, Bachman's hare, and the probably extinct Bachman's warbler, but during his day the quality and quantity of his observations, especially on small mammals such as moles and shrews, drew admirers on both sides of the Atlantic. The artist John James Audubon became his close friend. They collaborated on the three-volume Viviparous Quadrupeds of North America (1846−1853), for which the self-promoting Audubon took most of the credit even though Bachman did nearly all of the writing. As a naturalist, Bachman was Audubon's superior and objected to the artist's rushing into print despite inaccuracies. Bachman apparently did not object to the marriage of two of his daughters to Audubon's two sons. (Both of these daughters later died of tuberculosis, as did another daughter and both of Bachman's wives; Bachman seems to have been an effective disseminator of the tubercle bacillus.) Bachman's opposition to a prevailing view on polygenesis—the derivation of a species from more than one ancestor—makes him a still-relevant figure in the broader history of science.

Calhoun and others supported the positive good theory on slavery with an argument that blacks were not just intellectually inferior to whites; they were a separate species. The idea of polygenesis—that is, that there were multiple creations, not just the singular creation of Adam and Eve—was respectable during the 18th century (defended, for example, by Voltaire and David Hume), was widespread in Europe by the 19th century, and by 1830 had spread to the United States. Among its champions was the celebrated Swiss-born Harvard scientist Louis Agassiz. In 1839 polygenesis received a boost in the United States when the Philadelphia physician Samuel George Morton (1799−1851) published his long-awaited book, Crania Americana. Morton, one the world's foremost “craniologists,” used internal dimensions of skulls to support an argument that blacks were the “lowest grade of humanity.” Among Morton's most enthusiastic supporters was Dr Josiah Clark Nott (1804−1873), a native of Columbia, South Carolina, who made his mark in Mobile where he founded the Alabama College of Medicine. Nott became the South's leading physician-polemicist on racial theory. He used Morton's data to strengthen the case for polygenesis, black inferiority, and the positive good theory of slavery.

John Bachman, although a social reformer who ministered to both races, did not dispute the idea of black inferiority. However, he like other ministers was troubled by Morton's challenge to the biblical creation story. In 1850, Bachman published The Doctrine of the Unity of the Human Race Examined on the Principles of Science shortly before the American Association for the Advancement of Science held its third annual meeting in Charleston. Ravenel, Lewis Gibbes, Holbrook, Nott, and Bachman all presented papers. Bachman's paper on the “unity of the human race”—monogenesis as opposed to polygenesis—created a stir. Louis Agassiz, a frequent visitor to Charleston, attended the meeting and contested Bachman. After the meeting, Agassiz went to Columbia to spend 2 weeks with Dr Robert Wilson Gibbes (1809–1866), a Charleston native who had become a versatile physician-scholar and authority on paleontology. Gibbes took Agassiz to various plantations where Agassiz made observations on slaves that strengthened his conviction that blacks were a separate species. The Harvard scientist now sided completely with Morton and Nott on polygenesis. Bachman, meanwhile, was unable to convert any of his fellow Charleston naturalists, or any of the professors at the Medical College, to his point of view.

These events coincided with debates in Congress that led to the Compromise of 1850—five bills that defused a confrontation between slave states and free states on the status of territories acquired during the Mexican-American War. John C. Calhoun died that year, but his doctrine of states' rights and his positive good theory of slavery became mantras for pro-slavery southerners.

In a recent book entitled America's Longest Siege, Joseph Kelly argues that “the siege of Charleston” was not merely the siege of Fort Sumter; rather, it was a decades-long siege of southern thought led to a large extent by the South Carolina lowcountry planter aristocracy. Freedom of speech on slavery and states' rights virtually disappeared among white South Carolinians. Root causes included greed, fear, and preservation of a way of life because an estimated two-thirds of the state's private wealth consisted of slaves. During the war, the British-Irish reporter William Howard Russell attended a gathering of lowcountry rice planters and wrote in his diary: “These tall, thin, fine-faced Carolinians are great materialists. Slavery perhaps has aggravated the tendency to look at all the world through parapets of cotton bales and rice bags, and though more stately and less vulgar, the worshipers here are not less prostrate before the ‘almighty dollar’ than the Northerners”.

SECESSION AND CIVIL WAR (1860−1865): DR FRANCIS PEYRE PORCHER
Historian William J. Cooper argues that secession was not an inevitable result of the pro-slavery and pro–states' rights dogmas of the antebellum South. If South Carolina seceded, would the other southern states follow? South Carolina had acted alone during the Nullification Crisis of 1832; would the Palmetto State again be “hung out to dry”? Pro-secession “fire-eaters” advanced three arguments. First, the right to secede was implicit in the Constitution. Because the Union had been entered voluntarily it could be left voluntarily. Second, the federal government had not enforced the Fugitive Slave Law, and now northern opinion threatened abolition. Finally, Lincoln's election was intolerable, tipping as it did the balance of power in Washington. Although Lincoln did not call for the immediate abolition of slavery, he was clearly no friend of the South's “peculiar institution.” He had little first-hand knowledge of the South. He had no plan for reparations to slaveholders should slavery be abolished.

The Charleston physician-naturalists supported secession and, like other able-bodied men, served the Confederate cause. John Holbrook chaired the Examining Board of Surgeons for South Carolina and was a medical officer in the Confederate Army. Robert Wilson Gibbes served as Surgeon General of South Carolina. One physician-naturalist, Dr Francis Peyre Porcher (1824−1895), made himself useful through his knowledge of medicinal botany.

In 1847, Porcher had been the first honor graduate of the Medical College in Charleston, writing his thesis on the flora of the Carolina lowcountry. In 1848, he published “A Sketch of the Medical Botany of South Carolina” and in 1854 he reported to the American Medical Association on “The Medicinal, Poisonous, and Dietetic Properties of the Cryptogamic Plants of the United States.” He might have veered off into the emerging field of cellular pathology had the war not intervened, for in 1860 he presented a paper to the state medical association on “Illustrations of Disease with the Microscope; Clinical Investigations, with upwards of five hundred original drawings from nature and one hundred and ten illustrations in wood.” Porcher's knowledge of medicinal botany drew the attention of the Surgeon General of the Confederacy, Dr Samuel Preston Moore, a Charleston native who had relocated to Arkansas. Moore asked Porcher, then a surgeon in the Confederate army, to prepare a manual on botany to compensate for the effect of the Union blockade of Southern ports on Confederate drug supplies. Porcher's manual, Resources of the Southern Fields and Forests, Medical, Economical, and Agricultural. Being also a Medical Botany of the Confederate States; with Practical Information on the Useful Properties of the Trees, Plants, and Shrubs (1863), was widely used. It was so successful that a revised and expanded edition was issued 4 years after the cessation of hostilities.

The Civil War was disastrous for South Carolina, which lost 23% of its white male population of fighting age, the highest percentage of any Confederate state. John Holbrook lost all of his papers when Charleston was ransacked. He eventually retired to Massachusetts where he died in 1871. Robert Wilson Gibbes lost nearly everything including his extensive collection of fossils when Columbia burned shortly after William Tecumseh Sherman entered the city (February 1865). He died in 1866 “full of loneliness and despair.” The elderly and kindly Reverend Bachman, who despite northern roots had supported secession, lost his papers and was seriously roughed up by Union troops. True to his religious beliefs, he declined to identify his attackers.

The natural history movement faded during the closing decades of the 19th century. Darwinism dimmed enthusiasm for natural theology and the argument from design. Professionalization and compartmentalization of most branches of science discouraged talented amateurs or “gentleman” naturalists. The advent of anesthesia, the germ theory, and aseptic surgery opened new avenues for innovative physicians. Francis Porcher, the youngest of the physician-naturalists considered here, went on to a distinguished medical career and in 1890 was 1 of 10 Americans invited to attend the 10th International Medical Congress in Berlin. A few physicians soldiered on as naturalists in South Carolina and elsewhere, but the movement had by and large run its course.

PARTING THOUGHTS
Looking out on this audience, I see an aristocracy of talent dedicated to the advancement of scientific medicine. As William Osler put it: “Linked together by the strong bonds of community of interests, the profession of medicine forms a remarkable world-unit in the progressive evolution of which there is fuller hope for humanity than in any other direction”. Yet looking beyond this audience, beyond the salt marshes of the South Carolina lowcountry, I see a nation nearly as hyperpolarized as it was on the eve of the Civil War, a nation divided not as Blue versus Gray states by the Mason-Dixon line but as Blue versus Red states divided more or less (and fortuitously) by whether their ticks carry Borrelia burgdorferi, the agent of Lyme disease. Sadly, I see politicians of my own state voting to nullify the Affordable Care Act (just as their forebears nullified the tariff), voting to oppose expansion of Medicaid, and acting (at the time of this meeting) in such a way as to bring the federal government to a near-standstill. Like James Louis Petigru, I wonder whether we—Americans and, in a broader sense, all of Homo sapiens—will ever “get it right.” The root cause of at least some our troubles remains greed—aspiration to, or preservation of, an “aristocracy of wealth.” The social predicaments of the South Carolina physician-naturalists, and their tacit approval of slavery and states' rights, remind us that we are all at least to some extent prisoners of the prevailing paradigms and prejudices of our times, and that future generations may see us quite differently than we see ourselves. We forget this lesson at our own risk.

Image 1: Selected military, political, and ideological events between 1750 and 1865 (shown to the left of the timeline) and dates of major contributions including published treatises by selected South Carolina physician-naturalists (shown to the right of the timeline).

Abstract
Robert E. Lee's Army of Northern Virginia met the Army of the Potomac under George B. McClellan at Antietam Creek near Sharpsburg, Maryland on September 17, 1862. Before the day was done, nearly 23,000 men were killed, wounded, or missing, memorializing Antietam as the bloodiest single day in American military history. Dr. Jonathan Letterman, the Medical Director of the Army of the Potomac, Clara Barton, the “Angel of the Battlefield,” and Dr. Hunter McGuire, Chief Surgeon to and Medical Director of General Stonewall Jackson's Corps, were among the nursing and medical personnel engaged on that historic day. These three individuals provided medical and nursing care to the casualties at Antietam (and other Civil War battles), but perhaps more importantly, developed systems of casualty management that brought order and humanity to the battlefield. These models of care continue today in modern military medicine.

Introduction
The War Between the States provides an unfortunate but ideal opportunity to explore the evolution of battlefield medicine through the contributions of several individuals—Dr. Joshua B. Letterman, Clara Barton, and Dr. Hunter Holmes McGuire—to improving the medical care of soldiers on both sides of the conflict. Civil War casualties surpassed all other American wars in percentage of combatants killed in action, wounded and dead from all causes (particularly disease). The absolute total killed in action, wounded and dead from other causes in the war was also very high, about equivalent to World War II (1). Several factors accounted for the increased casualties: improved accuracy, range and power of the armaments employed, battlefield tactics of the day and poor public health conditions.

Tactics and Weapons
Many of the formally trained General officers of both armies received military education and training at the U.S. Military Academy, where they were instructed in battle tactics by Dennis Hart Mahan, the West Point professor of military science from 1830–1871 (2). Concentration of forces, rank and file battle formation, close quarters combat and an emphasis on flanking were military doctrine of the time, borrowed in large part from the Napoleonic experience. These battle tactics and the devastating power of the rifles and artillery used during the war resulted in very high numbers of killed and wounded in action. The basic infantry weapon was the Springfield rifled musket, accurate at 500 yards, firing a .58 caliber minie ball, which was actually a rifled bullet, not a smooth bore ball (3). Cannon were both smooth bore and rifled, improving in range, power and accuracy throughout the war. These cannon fired a variety of projectiles from solid shot to exploding shells, canister and chain, fired at close range with devastating effect (4). Enfilade fire, directed along the length rather than the breadth of a formation during a flanking maneuver, was particularly effective and lethal at Antietam.

Battlefield Medicine and Surgery at the Beginning of the Civil War
To put the Civil War in perspective, the U.S. population at the war's beginning was about 34 million. Nearly 4 million men, more than 11 percent of the entire American population, were engaged in the war (1). Most came from rural backgrounds, lacked immunity to communicable disease and were unprepared to be concentrated in close, unsanitary quarters, making them susceptible to illnesses such as dysentery, measles, smallpox and malaria. Military surgeons had little understanding of the causes of communicable disease and most treatments were ineffective. Basic necessities, particularly in the Confederacy later in the war, such as shoes, clothing, food and clean water, were in short supply. On average, the Confederate soldier was estimated to be ill or injured about 6 times over the course of the war (5,6). The viewpoint of the average soldier is more telling than statistics. From Pvt. Alexander Hunter, Company A, 17th Virginia Infantry on arrival at Hagerstown near Sharpsburg, Maryland before the Battle of Antietam: “Another day's march brought us to Hagerstown where the cornfields and orchards furnished our meals. The situation, in a sanitary point, was deplorable. Hardly a soldier had a whole pair of shoes. Many were absolutely bare-footed, and refused to go to the rear. The ambulances were filled with the foot-sore and sick” (7).

Most Civil War military surgeons were graduates of unregulated two-year medical schools. At the beginning of the conflict, most had never treated a gunshot wound, and very few were experienced in evaluating and treating the injuries of war. Although general anesthesia became available in 1846, most surgeons were untrained in surgical techniques and had not performed surgery. Lister's theory of sepsis and subsequent antiseptic techniques were not applied to surgical and post-operative care until after the war. While chest, abdominal and neurological surgery were rarely possible, treatment of extremity injuries was possible and necessary. Amputation was commonly practiced and became the primary surgical skill of the Civil War battlefield surgeon (5,6). The organization of medical care in 1861 when the war began was centered on the role of individual physicians rather than systems of care designed to handle mass casualties. Both armies were shocked at the high casualty rates and unprepared for the management of these casualties.

Prior to the onset of hostilities in 1861, the Medical Department of the Union army was small, numbering only one Surgeon General, thirty Surgeons, and eighty-four Assistant Surgeons. Some of these surgeons resigned their Union commissions to join the Confederate Medical Department. By the end of the war four years later, the Union Medical Department expanded to more than 10,000 surgeons (6).

The Medical Department of the Confederate States of America was established in February, 1861 by the “Act for the Establishment and Organization of a General Staff for the Army of the Confederate States of America” of the Provisional Congress. The act provided for a medical department of one Surgeon General, four surgeons, and six assistant surgeons. By the end of the war, the South had about 4,000 military surgeons (8).

Antietam
With the Peninsula campaign over and Richmond no longer threatened, Lee was in command of the Army of Northern Virginia. He turned his attention to northern Virginia, defeating the Army of the Potomac under Pope in July, 1862 at Second Manassas. As Pope retreated to Washington, Lee seized the initiative, crossing the Potomac into Maryland, just south of Frederick, with 55,000 men (9,10). Lee's grand strategy was to liberate Maryland, gather recruits sympathetic to the Confederate cause and, obtain much needed supplies. Jefferson Davis entertained the possibility that if Lee could defeat the Union on northern soil, the Confederacy might gain European recognition, perhaps providing much needed supplies and assistance in lifting the Union blockade of southern ports.

Lee drafted his plan of battle, Special Order 191, for his commanding generals on September 9, 1862. After Lee vacated Frederick, advancing toward Hagerstown, Maryland, a copy of S.O. 191 was found in a field by a corporal of the 27th Indiana, wrapped around three cigars (10). General George B. McClellan, now in command of the Army of the Potomac, had Lee's battle plan. He pursued Lee with 77,000 men, closing the gap between the armies near Sharpsburg, Maryland, where Lee chose to turn and face McClellan across Antietam creek (9,10).

On the morning of September 17, 1862, 130,000 soldiers were ready for battle. The day dawned gray and misty, but soon cleared. McClellan's battle plan was to turn both flanks and roll up Lee's army. Beginning at 6:00 AM with a Union assault through Miller's Cornfield, the battle proceeded roughly north to south along a three-mile long and half-mile wide front. The 30 acres of the Cornfield would change hands 6 times in three hours with 10,000 casualties. Union General Joseph Hooker reacted to the slaughter: “…the slain lay in rows precisely as they had stood in their ranks only a few minutes before” (9). The ferocious assaults and counter assaults at close quarters with musket and cannon, from the Cornfield to the north through the Sunken Road (also known as Bloody Lane) to the southern salient of Burnside's Bridge, lasted about twelve hours. The dramatic arrival of A. P. Hill's division from Harper's Ferry, just in time to attack the left flank of Union General Ambrose Burnside's forces, saved Lee's army from annihilation (9,10).

The battle ended as abruptly as it had begun. Total casualties on both sides, killed, missing and wounded, were about 23,000—more Americans died on September 17, 1862, than on any other day in the nation's military history (1,11), including World War II's D-Day. Lee expected McClellan to attack with much superior numbers on the following day, September 18th, but the attack did not come and there were no hostilities that day. The ambulance corps of both armies worked to clear the field of the injured and dead. The night of the 18th, Lee withdrew the Confederate forces west across the Potomac at Shepherdstown, Virginia (now West Virginia), ending the immediate hope that the Confederates could win on northern soil. The South also lost any possibility that any European countries would support their cause. Shortly thereafter, Lincoln issued the Emancipation Proclamation, changing the strategic focus of the war from preserving the union to abolishing slavery.

Dr. Jonathan Letterman
Jonathan Letterman was a native Pennsylvanian, graduating from Jefferson Medical College in Philadelphia in 1849, soon followed by military service as a U.S. Army Medical Department Assistant Surgeon in the Seminole Indian Wars with Stonewall Jackson. Assigned to the Army of the Potomac in June 1862, Major General McClellan promoted Letterman to the post of Medical Director of the Army of the Potomac. By September, Letterman had devised an efficient and, for the times, modern system of mass casualty management, beginning with first aid adjacent to the battlefield, removal of the wounded by an organized ambulance system to field hospitals for urgent and stabilizing treatment, such as wound closure and amputation, and then referral to general hospitals for longer term definitive management. This three-stage approach to casualty management, strengthened by effective and efficient transport, earned Letterman the title of “The Father of Battlefield Medicine” (12). While simple in design, the orderly and organized execution of a casualty management plan in the confusion of war, with very large numbers of casualties, was a massive undertaking. Each battle required advance planning and marshalling of vital resources, such as skilled and trained first aid attendants near the battlefield, ambulance attendants and drivers, wagons, mules, nurses, surgeons, medical supplies, clean water, food and firewood. Communications among the cooperating parties were difficult, and, of course, the rate at which casualties were received could not be controlled. Letterman's official battle report outlines in detail the logistical challenges of providing medical support to the army (12).

The management of casualties was organized at the unit level—first aid at the regimental level with triage to the mobile field hospitals at the division and corps level. The ambulance corps was established by U.S. Army Special Order 147 in August of 1862, following the Seven Days Battle that ended the Peninsular Campaign in July of 1862. Letterman's model of casualty management became the standard for the Union Army by an act of Congress in March 1864. At First Manassas in 1861, with about 5,000 combined dead and injured soldiers, it took a week to get the casualties off the field. At Antietam, with about 23,000 dead and wounded, all the casualties were removed from the battlefield in 24 hours (13,14).

The mass casualty management system that Letterman devised was extensively utilized after Antietam, perhaps no better than at Gettysburg. There were more than 50,000 casualties, dead and wounded during the three day battle in early July, 1863. At the close of the battle, 22,000 wounded Union and Confederate soldiers were treated according to the Letterman model. A large general hospital, Camp Letterman General Hospital, was constructed at Gettysburg to provide care to the wounded long after the armies had moved on. Once the general hospital closed, those needing continuing hospitalization were shipped to larger hospitals in Philadelphia, Baltimore, Washington and Richmond (15).

Clara H. Barton
Clara Barton was born in Massachusetts in 1821 and raised in a socially conscious family, influenced by her parents who favored abolition and championed women's rights. An avid learner, Barton received both home and formal education, becoming a teacher in Massachusetts. She returned to formal education at the Clinton Liberal Institute in New York State, a respected school overseen by the Unitarian Universalist Church. She then moved to Bordentown, New Jersey and, pursuing public service, established the first free public school in New Jersey. Barton left teaching in 1854, moved to Washington, D.C. and was working in the U.S. Patent Office there at the beginning of the war.

In response to the declaration of war at Fort Sumter in early April, 1862, the Union mobilized to defend Washington, D.C. The 6th Massachusetts Infantry, passing through Baltimore on April 19th, 1862, was attacked by southern sympathizers. Several soldiers were killed and others injured. The wounded were taken to the Senate Chamber of the U.S. Capital where they were personally cared for by Barton, beginning her involvement in the Civil War.

Partly because of her experience with the 6th Massachusetts Infantry, Barton was keenly aware that the U.S. Army Medical Department was unprepared for the treatment of casualties. She successfully petitioned the military, with the help of U.S. Senator Henry Wilson of Massachusetts, to assist in bringing supplies and personal aid to battlefields in 1862, a substantial logistical problem. Volunteers, such as Barton, provided an invaluable service early in the war until larger charitable organizations, such as the U.S. Sanitary Commission, were able to assist the Union Army on providing basic necessities, sanitation and medical support for the troops (16).

Among the battles that Barton attended were Cedar Mountain, Second Manassas, Antietam, and Fredericksburg. At Antietam, Barton waited with Burnside's Ninth Corps as the only woman. She arrived on the northern edge of Miller's Cornfield around noon on September 17th with wagons of supplies while the battle was still being fought. The surgeons she personally assisted were astonished to see her but gratified. It was there that she earned the title of “The Angel of the Battlefield” from a Union surgeon, Dr. James Dunn (17).

Dr. Hunter Holmes McGuire
Hunter Holmes McGuire was born in Winchester, Virginia, in 1835, the son of a respected physician and surgeon, Dr. Hugh Holmes McGuire. Hunter received his initial medical degree from Winchester Medical College (Virginia) in 1855 and, three years later, entered Jefferson Medical College in Philadelphia. McGuire showed signs of leadership at an early age. In 1859, following John Brown's execution in the aftermath of the ill-fated raid on the arsenal at Harper's Ferry, Brown's body was brought to Philadelphia and became a source of friction between the northern and southern medical students. McGuire organized the withdrawal of several hundred southern medical students from Jefferson, many of whom enrolled in the Medical College of Virginia in Richmond as did McGuire. Following graduation, McGuire returned to Winchester and in 1861 enlisted in the Confederate Army as a private. The Confederate Surgeon General soon reassigned McGuire as the medical director of the Army of the Shenandoah under Thomas J. (Stonewall) Jackson. McGuire served continuously with Jackson as his medical director and as a trusted confidant and surgeon. Jackson was shot through the left arm and right palm at Chancellorsville by friendly fire in May of 1863. McGuire skillfully amputated Jackson's arm and personally cared for him until Jackson's death eight days later.

As the medical director, McGuire organized the medical service of the Army of the Shenandoah in 1861, beginning with hospital administration, operating procedures and transport. His “genius for efficient organization” (18,19) soon extended to the battlefield where he organized the treatment of casualties much as Letterman had done. After initial treatment, adjacent to the battlefield by the Regimental Infirmary Corps, the Ambulance Corps transported the wounded to Reserve Corps or mobile field hospitals for urgent treatment, and then to general hospitals in the rear and finally, for those needing extended care, to hospitals in Richmond and other major cities. As in the case of the Army of the Potomac and Letterman, McGuire was also responsible for the challenging logistics of supply and transport.

Legacies
Dr. Jonathan B. Letterman resigned his commission in December, 1864, completing his service to the Union Army and moved to San Francisco where he practiced medicine and served as a coroner. His memoir, Medical Recollections of the Army of the Potomac, was published in 1866. Letterman died at the young age of 48 on March 15, 1872 and was later interred in Arlington National Cemetery. The Army Hospital at the Presidio was named Letterman General Hospital in 1911, honoring the military physician who pioneered the care of battle casualties.

Clara H. Barton was asked by President Lincoln as the war ended to assist in locating and identifying the missing in action, including the thousands of unknown who died in military prisons. Before her work was finished, more than 22,000 missing soldiers were identified (16). She is most known for her role in founding the American Red Cross, following a trip to Europe where she became familiar with the Geneva Convention and the International Red Cross. Because of concerns that any international intervention in U.S. Wars would be a violation of the Monroe Doctrine, the American branch of the International Red Cross was not authorized by Congress until 1882 (16,17,20).

Dr. Hunter Holmes McGuire was a prisoner of war at Waynesboro in March of 1865. Paroled by General Sheridan, McGuire continued service with Lee's army until the war ended at Appomattox in April, 1865. He returned to Richmond as a professor of surgery in July, 1862, leading to a distinguished academic surgical career. He was a founder of the University College of Medicine in Richmond in 1892, later merged with the Medical College of Virginia. Highly respected by his peers, McGuire was elected president of the Southern Surgical association and the American Medical Association (18). Today, The Hunter Holmes McGuire Veteran's Administration Medical Center, is named in his honor.

DISCUSSION
Lindberg: Bethesda: I very much enjoyed your presentation. Just a minor footnote to the Baltimore incident. I think it said that the first six federal casualties of the war occurred in Baltimore, because of the local feelings you referred to. They had another peculiarity there at the time—namely, two railroad stations, more or less like Pennsylvania Station, Grand Central in New York, which wouldn't communicate with each other. So passengers had to get off one train and walk three or four blocks to the other station, and that's where the shooting occurred. That also made Lincoln, when he was on his way to inauguration, his staff refused to allow him to be exposed to exactly that circumstance, and he came in the darkness of night at 2 a.m.—a move he regretted for the rest of his life. He felt embarrassed about that. But in order to get federal troops to Washington they actually brought them by boat to Annapolis, because they didn't dare go through Baltimore. Still a tough place.

Tooker: Philadelphia: Thank you.

REFERENCES
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3. Civil War Small Arms. National Park Service, U.S. Department of the Interior. Available at: http://www.nps.gov/archive/gett/soldierlife/webguns.htm.
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20. Skocpol T, Munson Z, Karch A, et al. Patriotic Partnerships: Why Great Wars Nourished Civic Volunteerism. In: Katznelson I, Shefter M, editors. Shaped by War and Trade: International Influences on American Political Development. Princeton University Press; 2001.

In late December 1861 Northern newspapers buzzed with rumors about a high-ranking Confederate officer who had committed suicide. Within days the victim was identified as Philip St. George Cocke, one of Virginia’s wealthiest and largest planters. Cocke, a West Point graduate, had been appointed commander of Virginia’s state forces by Governor John Letcher in the earliest days of hostilities. He lost his coveted rank of brigadier general, however, when Southern state militias were folded into the Confederate Army.

Although he received a promotion to brigadier general after the First Battle of Bull Run, Cocke never recovered from being demoted to colonel and felt that his battlefield successes were not sufficiently acknowledged. The perceived slights, on top of the strain of war, combined to take a huge toll on Cocke’s psychological and physical health. He retreated to his plantation a broken man, and on the day after Christmas 1861, he shot himself in the head with a pistol.

Cocke may well have been the highest-ranking Confederate soldier to die by his own hands during the Civil War, but he was not alone. The historical record is peppered with cases of soldiers, Northern and Southern, taking their own lives. While most suicides likely occurred as a consequence of what was then called “battle shock,” quite a few took place in camp, even before being shipped off to the front.

The Richmond Dispatch, for example, reported that a soldier identified only as E. White committed suicide while in camp near Savannah, Ga., in October 1861. The grandson of Kentucky Senator John Crittenden, a 26-year-old private named Coleman, who was attached to the 1st Florida Regiment, cut his throat in late August 1861 while stationed near Pensacola. No explanation was offered other than he had been “under a state of mental derangement.” A prominent lawyer from Mobile, Ala., had enlisted in one of the volunteer companies formed in that city in early summer 1861; he, too, slit his throat while making his way to the front.

None of these Confederate soldiers left a suicide note, so it is impossible to know with certainty what drove each to commit such a rash act. While it is entirely possible that non-war related factors – pre-existing conditions or an unstable home life, for instance – contributed significantly to their deaths, war and one’s looming participation in it, the common thread in all these suicides, almost certainly proved the decisive factor. But the question remains: why were so many of them Southern? Was there something about Southern society that, combined with the stress of war, made suicide more likely? And what effect did so many suicides have on a society that before the war had roundly, even punitively, condemned the act?

Each suicide is a thing unto itself, but we can offer a few conjectures. Importantly, men, especially white men in the South, well understood the expectations Victorian society demanded of them in wartime. Honor and duty required their martial participation. So in the wake of the firing on Fort Sumter and Lincoln’s call for troops, Southern white men heeded their new nation’s call to arms and flocked to recruiting stations.

The “Boys of ’61” were pulled into military service by rage militaire a sense of adventure, but they were also pushed into service by patriotic womenfolk who, despite reservations, implored their husbands and sons to enlist. To resist would raise questions about one’s manhood as well as commitment to nation. Consequently, thousands reflexively rushed off to war without much deliberation or contemplation.

As Southern recruits mustered in camps, the reality of what they faced set in. While many a green soldier longed to “see the elephant” – a colloquial term referring to engaging in battle – eagerness often gave way to anxiety and a plethora of fears: of dying, of killing, of failure, of the unknown. If any of those fears were made manifest, a soldier’s courage would be called into question, as appears to have been the case with Charles Robinson, a member of the newly constituted Independent Scouts of Mobile that was mustering in June 1861. When fellow recruits accused him of being a coward, Robinson retorted that he would show them how a Roman could die, then plunged a knife into the carotid artery in his neck.

While most new soldiers punched through that initial reservation and persevered, some became emotionally paralyzed in battle and ultimately unable or unwilling to fight. Take the case of Capt. Christopher Fisher of the newly formed Petersburg Cavalry, a “man of high social position at home.” Fisher first began to show signs that he was “laboring under mental aberration” as his company faced battle near Pig Point, Va., in the early weeks of hostilities. According to a newspaper account, Fisher had become “depressed in spirit” after recognizing that this company was about to be “cut to pieces by the enemy.”

Sympathetic officers and enlisted men, apprehending his weakened state of mind, persuaded him to leave his post and return home. Fisher complied, but en route he drew a pistol, shot himself and sustained an injury that felled him from his horse. He stumbled, ran a short distance, then shot himself again, through the head, dying a few minutes later. Suicide permitted the young captain to escape the taint of cowardice that surely would have followed him had he lived, just as it spared him the pain of facing loved ones as a man who had failed the battlefield test.

Suicide in the antebellum South, as in the rest of the nation, was roundly condemned in moral and religious terms. Protestant and Catholic theology decried suicide as a mortal sin, while laypeople often equated the act with cowardice and selfishness. Ministers railed against the act as an encroachment on God’s authority. Preachers admonished parishioners to follow the example of the long-suffering Job, who patiently endured endless personal suffering. And while the legal remedies to punish suicide victims had largely disappeared from American practice – namely, forfeiture of the suicide victim’s inheritance to the state – the stigma surrounding suicide steadfastly remained at the outbreak of the Civil War.

Indeed, the war stands as an important turning point in the way Southerners came to view suicide and helped usher in a more tolerant, sympathetic attitude toward those who died by their own hands. Consider the newspaper coverage of the death of Captain Fisher. We learn that Fisher “was greatly beloved by his company,” members of whom believed he was a brave man. Excessive concern for his company, not fear or shame, the newspaper explained, had caused Fisher to end his own life.

General Cocke, too, had been eulogized in similar fashion. The Richmond Enquirer even equated Cocke’s suicide with a battlefield death by proclaiming him a “martyr to his patriotism as if he had fallen in the field of battle.” Readers were assured that his “heart and soul were thoroughly enlisted in the noble cause of Confederate independence.” The Richmond paper further vindicated Cocke by denying he bore blame for the self-murder, explaining that he had shot himself while “under the impulsion of a mental aberration that extinguished all responsibility.”

Sympathetic responses extended to enlisted Confederate soldiers as well as officers. On Dec. 14, 1861, for example, the Richmond Daily Dispatch, reported on yet another soldier suicide, this one from the 9th South Carolina Regiment. While friends were at a loss to explain why Burgess killed himself, the newspaper surmised that he was “tired of life and had concluded to try the realities of another world.” Noting that this was the second such suicide in a few days, the newspaper abhorred “such deplorable waste of life.” The piece further opined that “men in war become more reckless of their lives and attempt, through a mistaken notion, to relieve themselves of a burden too heavy to bear.”

Another measure of changing attitudes toward Civil War victims of suicide can be seen in the public sympathy victims received after their deaths. The lawyer from Mobile who cut his throat en route with his company to the front was accorded considerable respect following his suicide. Two companies escorted his coffin to the cemetery for burial, where he received military honors. The Knoxville Register reported that “a large number of our citizens” attended the funeral, which was presided over by a minister, suggesting at least some religious rituals were observed. Similarly, a military detachment accompanied the remains of Thomas Stringham, a 22-year-old German Virginia man who killed himself while encamped near Norfolk with his company in October 1861. In a display of community reverence, members of the Norfolk Tailors Society appeared at burial-site services.

If some Southerners expressed compassion and support for soldiers who died by their own hands, others failed to make the connection between suicidal behavior and wartime experiences. Modern observers, many of whom witnessed American soldiers returning from Vietnam, Iraq and Afghanistan, are keenly aware of the possible contribution of trauma experienced in war to mental illness. But 19th-century Americans had no such understanding that exposure to battle sometimes resulted in psychiatric breakdown or debilitation.

Consequently, when a soldier (or, after the war, a veteran) developed severe signs of mental distress including suicidal tendencies, the causal connection to his military duty eluded many people, even family members and professional caretakers. As was common before the field of psychiatry matured, social pathologies like alcoholism were confused as a cause, not a symptom, of mental illness. Consequently, bystanders trying to explain why “a poor unfortunate soldier” attempted suicide in June 1862 said he had been made “delirious from liquor.” Likewise, masturbation was to blame for Joseph Henderson’s violent threats to himself and others, not his stint as a soldier in “Price’s Army” in Missouri or the “many fatigues” he had undergone there.

The stories of Confederate soldiers who attempted or committed suicide get us closer to a full accounting of the personal costs of the Civil War. Losses in dead, wounded and treasure have been well-documented; individual suffering, less so. And while suicides occurred among Union soldiers, there is evidence to suggest suicides occurred more frequently in the South during the war and following the defeat and collapse of the Confederacy, as broken soldiers returned home burdened with combat stress as well as the herculean task of rebuilding themselves, their families and the region.

Their stories also illuminate a “community of suffering” that emerged in the South during and after the Civil War that served as a catalyst for shifting ideas about suicide and manhood, opening the door for a more empathetic treatment of suicide victims. Southern soldiers who died by suicide, just as those who died by a sniper’s bullet, an exploding shell or typhoid were, to their minds, martyrs to patriotism.

Diane Miller Sommerville, an associate professor of history at Binghamton University, is the author of the forthcoming “Aberration of Mind: Suicide, Civil War and the American South,” for which she received a fellowship from the National Endowment for the Humanities. An expanded and fully cited version of this essay will appear in a forthcoming volume of Civil War History.

The primary form of Civil War surgery was the amputation. The common use of the minie ball, named after co-inventor Claude Etienne Minié in the American Civil War greatly increased catastrophic injuries. Made with soft expanding lead, when the mini ball struck flesh, bones and major organs the injuries were devastating.

A minie ball could be accurately fired from 1,000 yards and the basic line-formation tactics of the Civil War had not adapted to new weaponry. It could easily shatter bones and when faced with these types of injuries, Civil War doctors of this age often had no choice but to amputate.

This may seem archaic but due to the lack of time available to doctors to perform surgery, the high-risk of infection, and the catastrophic destructive power of these bullets, the decision to amputate was typically the right one.

The success rate for amputees was roughly 75% and these odds were good considering the awful nature of the injuries. Many injuries and death were caused by cannonballs, canister shot, shells and bayonets, but the majority of injuries were from bullets.

A woeful 1% of doctors in the Civil War had prior experience as surgeons. Doctors learned as they went and adapted quickly with practice and slowly gained practical experience. Early on there were many mistakes made, and men died from it. But as the war went on the doctors’ skills improved and the care provided increased.

A good surgeon could amputate a limb in under 10 minutes by using a bonesaw and other instruments. Chloroform was used when available to render the patient unconscious and morphine was utilized as a pain-reducer.

About Civil War Surgery and Civil War Doctors

The bone was sawed clear through and the limb was disposed of often in a pile of other limbs form previous amputations. Next, the arteries were tied-off with silk, horsehair or cotton thread to stop blood flow to the area. Then the bone would be filed down smooth to prevent the sharp edge from protruding and causing future damage to the area operated on.

Finally, using a flap of skin that was left, it was folded over to create the stump with a hole for fluids to drain. Then the wound was bandaged and the solider was set aside to rest and recover. If infection or gangrene didn’t set in after 48 hours, the chances of survival were greatly improved. When “surgical fevers” did set in, the chance of survival was just over 10%.

Basically the closer the amputation was to the body, the less chance for survival. When a solider came in with a head, stomach or chest wound, they were typically put to the side as they were almost always fatal injuries beyond the help of Civil War medicine. This allowed the Civil War doctors to help the soldiers who had a chance to survive, rather than waste their time on those with a lesser chance.

The skill involved in Civil War surgery developed sharply over the course of the war and the efforts of the doctors really paid off for those lucky enough to survive the terrible injuries suffered on the field of battle.

It was not only doctors and nurses who were, at times, incompetent but army officers as well. At least so Clara Barton often thought. She was a strong-minded woman, and a bit inclined to think the worst of her superiors and associates. When the war broke out Miss Barton was working in the patent Office in Washington. Deeply moved by the distress of the soldiers after First Bull Run she wrote a letter to the Worcester (Massachusetts) Spy asking for food, clothing, and bandages for the soldiers. Provisions poured in-and she had found her mission. Never formally associated either with the Sanitary Commission or, except for a brief interlude, with the army, she conducted something of a one-woman relief organization. She carried on her beneficent activities with the Army of the Potomac, the Army of the James, around Charleston, and in and around Washington. After the war she was the moving spirit in the establishment of the American Red Cross, and for over tzventy years its director.

This excerpt comes from her war diary.

No one has forgotten the heart-sickness which spread over the entire country as the busy wires flashed the dire tidings of the terrible destitution and suffering of the wounded of the Wilderness whom I attended as they lay in Fredericksburg. But you may never have known how many hundredfold of these ills were augmented by the conduct of improper, heartless, unfaithful officers in the immediate command of the city and upon whose actions and indecisions depended entirely the care, food, shelter, comfort, and lives of that whole city of wounded men. One of the highest officers there has since been convicted a traitor. And another, a little dapper captain quartered with the owners of one of the finest mansions in the town, boasted that he had changed his opinion since entering the city the day before; that it was in fact a pretty hard thing for refined people like the people of Fredericksburg to be compelled to open their homes and admit these dirty, lousy, common soldiers," and that he was not going to compel it.

This I heard him say, and waited until I saw him make his words good, till I saw, crowded into one old sunken hotel, lying helpless upon its bare, wet, bloody floors, five hundred fainting men hold up their cold, bloodless, dingy hands, as I passed, and beg me in Heaven's name for a cracker to keep them from starving (and I had none); or to give them a cup that they might have something to drink water from, if they could get it (and I had no cup and could get none); till I saw two hundred six-mule army wagons in a line, ranged down the street to headquarters, and reaching so far out on the Wilderness road that I never found the end of it; every wagon crowded with wounded men, stopped, standing in the rain and mud, wrenched back and forth by the restless, hungry animals all night from four o'clock in the afternoon till eight next morning and how much longer I, know not. The dark spot in the mud under many a wagon, told only too plainly where some Poo fellow's life had dripped out in those dreadful hours.

I remembered one man who would set it right, if he knew it, who possessed the power and who would believe me if I told him I commanded immediate conveyance back to Belle Plain. With difficulty I obtained it, and four stout horses with a light army wagon took me ten miles at an unbroken gallop, through field and swamp and stumps and mud to Belle Plain and a steam tug at once to Washington. Landing at dusk I sent for Henry Wilson, chairman of the Military Committee of the Senate. A messenger brought him at eight, saddened and appalled like every other patriot in that fearful hour, at the weight of woe under which the Nation staggered, groaned, and wept.

He listened to the story of suffering and faithlessness, and hurried from my presence, with lips compressed and face like ashes. At ten he stood in the War Department. They could not credit his report. He must have been deceived by some frightened villain. No official report of unusual suffering had reached them. Nothing had been called for by the military authorities commanding Fredericksburg.

Mr. Wilson assured them that the officers in trust there were not to be relied upon. They were faithless, overcome by the blandishments of the wily inhabitants. Still the Department doubted. It was then that he proved that my confidence in his firmness was not misplaced, as, facing his doubters he replies: "One of two things will have to be done-either you will send some one to-night with the power to investigate and correct the abuses of our wounded men at Fredericksburg, or the Senate will send some one tomorrow."

This threat recalled their scattered senses.

At two o'clock in the morning the Quartermastcr-General and staff galloped to the 6th Street wharf under orders; at ten they were in Fredericksburg. At noon the wounded men were fed from the food of the city and the houses were opened to the "dirty, lousy soldiers" of the Union Army.

Both railroad and canal were opened. In three days I returned with carloads of supplies.

No more jolting in army wagons! And every man who left Fredericksburg by boat or by car owes it to the firm decision of one man that his grating bones were not dragged ten miles across the country or left to bleach -in the sands of that city.

The history of Chicago's hospitals begins with an almshouse established by Cook County as part of its responsibility to provide care for indigent or homeless county residents, and for sick or needy travelers. Located at the corner of Clark and Randolph streets, this public charity was in operation as early as 1835. It did provide medical attendance, but such places typically crowded the ill together with the healthy poor, the insane, and persons who were permanently incapacitated.

Unlike Cook County, the city of Chicago had no legal mandate to care for the sick poor, but its charter did charge it with guarding against “pestilential or infectious diseases.” Cholera had hit the area in 1832, and smallpox and scarlet fever were familiar to many. By 1843 fear of epidemic prompted city officials to build the first institution devoted exclusively to medical care in Chicago, a small wooden structure located on the far northern border of the city. Ironically, it was built on land bought for a cemetery. This first “hospital,” a frame structure at North Avenue and the lakeshore in what would become Lincoln Park, was designed to keep victims of contagious disease away from the center of population. Rebuilt after a fire, in 1852 it began to segregate smallpox cases from cholera cases, but when cholera threatened Chicago in 1854, the city council authorized a separate though only temporary hospital at 18th and LaSalle streets. The city kept the smallpox hospital at North Avenue and even built a two-story building there, but it perished in the fire of 1871. Beginning in 1874, a series of new hospitals to isolate contagious diseases was built on the Southwest Side of the city, near the courthouse at 26th and California.

Institutions like the smallpox hospital and the temporary cholera hospital were not meant to be locations of general medical care, and as early as 1837 citizens were suggesting the city build a general hospital. It was not until a decade later, however, that both city and county officials worked with physicians from Rush Medical College to establish the first such hospital in the area, at North Water and Dearborn streets. Newly opened and seeking students, Rush College wanted a hospital to fill a need for clinical education. Rush provided the doctors, the county supplied the medicine, and the city paid for the building rental. However, it soon became evident that the accommodations were inadequate for the large number and variety of patients, and the hospital went out of business.

Rush physicians soon incorporated another general hospital, called the Illinois General Hospital of the Lakes, which opened in 1850 with 12 beds in the old Lake House Hotel at Rush and North Water Streets. The charge was three dollars per week per patient. The doctors asked the Sisters of Mercy, a Roman Catholic order, to provide nursing care, and in the spring of 1851 transferred control to the Sisters. With a new charter, the hospital was renamed Mercy Hospital. Cook County supervisors paid Mercy to care for county patients. The oldest continuously running hospital in Chicago, it moved in 1853 to a new building at Wabash and Van Buren and in 1863 was relocated to its present campus at 26th and Calumet. Rush College retained the privilege of teaching medical students there until 1859, when Mercy switched affiliation to the Chicago Medical School (later known as Northwestern University Medical School).

Medical sectarians, some with unorthodox therapeutic practices, founded their own hospitals, such as the Hahnemann Hospital, which opened in the early 1850s. Popular despite unyielding criticism from “regular” physicians, homeopaths held that disease could be cured using very small doses of medicines rather than the typically large amounts of strong, even potentially lethal drugs other doctors prescribed. Homeopathy had a large following in Chicago and elsewhere in the nineteenth century, and this was not surprising, since minimalist therapies such as theirs were usually easier on the body. Their support declining by the early twentieth century as scientific medicine became more accurate and effective, homeopathic medical colleges found improvement in medical education difficult to implement, and their hospitals closed or adopted traditional techniques. During the mid-nineteenth century, however, homeopaths in Chicago held a strong hand. Friction between them and regular medical practitioners became a political battle in 1857, when the former sought representation on the medical staff of what was to be the new city hospital at 18th and LaSalle streets. The argument prevented the institution from opening until 1859, when Rush faculty members rented it for use as a private hospital. In 1862, the U.S. Army commandeered it for a military hospital, until the Civil War ended and the county leased it. Cook County finally had a relatively permanent hospital. As the number of charity cases grew, however, the old building proved too small, and County Hospital moved to new pavilions at the present site at Wood and Harrison Streets in 1876. Larger structures replaced these beginning in 1912, and these in turn were replaced in the first years of the twenty-first century.

In 1847 a Chicago physician built a private retreat for the insane just north of the city, and in 1854, when the county moved its almshouse to a site known as “Dunning” 12 miles northwest of the city, an asylum was among the buildings constructed. Authorities transferred this asylum, the Cook County Hospital for the Insane, to the care of the state of Illinois in 1912, and the name changed to Chicago State Hospital.

Institutional efforts against tuberculosis began with the Chicago Tuberculosis Institute, which established the Edward Sanatorium in 1907. The Municipal Tuberculosis Sanitarium, funded by the city, opened in 1915 at Crawford and Bryn Mawr Avenues. To care for sick and injured sailors who worked on the Great Lakes, the federal government set up a hospital in 1852 on the grounds of Fort Dearborn. It later moved north of the city to what became the Uptown neighborhood. After World War I, the United States Public Health Service established several large hospitals, forerunners of present-day Veteran's Hospitals. The Hines facility in Maywood was among the largest.

Seen as part of a church's mission, religious hospitals were shaped by a charitable imperative and a desire to save souls while caring for the sick. Religious symbols and the presence of religious nursing orders provided constant reminders of spirituality. St. Luke's Hospital, a charity of Grace Episcopal Church on the Near South Side, began in 1865 in a small frame structure at 8th and State Streets, eventually moving into larger buildings on south Indiana and Michigan Avenues. The hospital remained at that site for almost a century, merging in 1956 with Presbyterian Hospital and Rush Medical College on the Near West Side. Lutheran pastor William Passavant established the 15-bed Deaconess Hospital at Dearborn and Ontario Streets in 1865. Destroyed by the 1871 fire, in 1884 it reopened at Dearborn and Superior as the Emergency Hospital, later named Passavant after its founder. In 1920, Northwestern University Medical School adopted Emergency as a site for clinical instruction. Methodist Wesley Memorial Hospital, established in 1888, joined Passavant as part of Northwestern's Chicago campus in 1941.

The Alexian Brothers, a Roman Catholic male nursing order originating during the bubonic plague of the thirteenth century, started a small hospital for males in 1866. Its first substantial building was at Dearborn and Schiller. After two years, Alexian moved to larger quarters at North and Franklin. It rebuilt after the fire, moving in 1896 to Belden and Racine and then to Elk Grove Village in 1966. The Sisters of Charity began St. Joseph's Hospital in Lake View in 1868. It now serves the community from a modern high-rise building at Diversey Avenue near the lake. Other early Catholic hospitals were St. Elizabeth's, founded near Western and Division in 1887 by the Poor Handmaids of Jesus Christ, and St. Mary of Nazareth Hospital, established in 1894 by the Sisters of the Holy Family of Nazareth in the same neighborhood. St. Mary's served the Polish-speaking immigrant community.

Early Chicago Jews founded a hospital at LaSalle and Schiller in 1866. Like nearby Alexian Brothers, this institution fell victim to the fire, but Jewish Hospital did not rebuild immediately. The family of philanthropist Michael Reese made large contributions, and the hospital bearing his name arose in 1882 at Ellis Avenue and 29th Street, becoming by 1950 the largest charity-sponsored hospital in Chicago, with 718 beds. The increasing population of Jews on Chicago's Near Southwest Side prompted the opening of Mt. Sinai Hospital near Douglas Park in 1919.

The influx of German immigrants into the Chicago area led to the 1883 founding of the German Hospital. It was renamed Grant Hospital during World War I. Baptists established the Chicago Baptist Hospital in 1891, and Methodists founded Bethany Methodist. By 1897, Lutherans had built Augustana, Swedish Covenant, the Norwegian-American Hospital, and the Lutheran Deaconess Home and Hospital. Early twentieth-century Catholic groups started St. Anne's, St. Bernard's, and Columbus hospitals.

Several Chicago hospitals have aimed at specific types of patients. The Illinois Charitable Eye and Ear Infirmary began in 1858 under the direction of ophthalmologist Edward Lorenzo Holmes. In 1865, Mary Harris Thompson founded the Chicago Hospital for Women and Children, chiefly to serve widows and orphans of Civil War victims. Renamed the Mary Thompson Hospital when she died in 1895, it opened on Rush Street, then moved to West Adams Street. Julia F. Porter endowed the Maurice Porter Memorial Free Hospital for Children in 1882 in memory of her son. In 1903 it took the name Children's Memorial. Joseph B. De Lee founded the Chicago Lying-In Hospital and Dispensary in 1895 in a tenement house on Maxwell Street in an effort to lower the high neonatal mortality rates. The Martha Washington Hospital advertised itself as a haven for alcoholics, and the Frances E. Willard National Temperance Hospital, named after the famous temperance advocate from Evanston, was for nondrinkers. It was dedicated to proving that diseases could be cured without the use of alcohol or alcohol-based medicines.

Until the mid-twentieth century, many Chicago hospitals refused to treat African American patients or employ black doctors and nurses. Daniel Hale Williams, one of the first African American surgeons in Chicago, organized Provident Hospital in 1891 in an effort to ensure hospital services to African Americans in Chicago and to provide black health care workers a place to practice and learn.

Beginning in the last decade of the nineteenth century, groups of physicians and physician-entrepreneurs established for-profit hospitals such as the Lakeside Hospital, Garfield Park Hospital, Westside Hospital, and Jefferson Park Hospital. Later examples of this type included North Chicago, Washington Park, Ravenswood, South Shore, Washington Boulevard, Burnside, Chicago General, John B. Murphy, and Belmont hospitals. Most of these were small and some lasted only a few years. Others became nonprofit institutions and continued to serve without investor ownership.

Reforms in nursing and a new understanding of the importance of cleanliness made the hospital a safer place for most patients by the end of the nineteenth century. Medicine began to incorporate developments in chemistry and biology, and aseptic surgery and clinical laboratories became effective tools in health care. Such changes in technology paralleled tremendous growth in population from immigration, which strained existing municipal services, including the provision of medical care. Hospital construction by both public and private agencies was one result. Tax-supported hospitals were built by the city, the county, the state, and federal government. Private hospitals included institutions owned or operated by medical schools, religious groups, individual doctors or groups of physicians, lay boards, and even companies such as railroads. Especially in a city filling with immigrants, a hospital could be a place of comfort to particular beliefs, customs, languages, and races, as well as a site of medical care.

Insurance programs beginning in the 1930s encouraged hospital development, and as the Hill-Burton plan took effect after World War II, hospitals all over the United States were built or expanded. As the number of available beds increased, so did competition for patients among neighboring institutions. By 1950, with a population of 3.6 million, Chicago had 84 hospitals, including public and private sanatoria. The majority were nonprofit, receiving major funding from patient fees (often at least partly paid by insurance), donations, and endowments.

As government reimbursement programs initiated in the 1960s expanded to encompass so many patients that tax resources stretched thin, agencies demanded briefer hospital stays. New technologies allowed patients to be discharged earlier. Beds began to go unfilled and hospitals faced declining revenues. Many closed or consolidated, and the number of hospitals in Chicago fell to approximately 50 by the late 1990s. The advent of health-maintenance organizations (HMOs) was another factor in the loss of hospital income, since these organizations typically contracted for care at lower fees than traditional insurance paid. Hospital ownership began to consolidate as large corporations or associations sought economies of scale by purchasing formerly independent institutions.

Bibliography
Bonner, Thomas N. Medicine in Chicago, 1850–1950: A Chapter in the Social and Scientific Development of a City. 2nd ed. 1991.
Chicago Medical Society. History of Medicine and Surgery and Physicians and Surgeons of Chicago. 1922.
Duis, Perry. Challenging Chicago: Coping with Everyday Life, 1837–1920. 1998.